Q-Based Healthcare Dropship Inquiry

Please use this form to to supply the business details we need to qualify you for our dropshipping program. A marketing representative will get in contact with you as soon as possible to help integrate you into our dropshipping system. (Please note your information will kept in strictest confidence. If you do not wish to provide detailed information you should consider our affialite program.)

Company Name:
Business Address:
Business Telephone:
Website:
Your Shopping Cart Platform:		e.g. volusion, cube cart, etc.
Approx Monthly Visitors:
Email:
Tax ID Number:

How long in Business?
Type of Business:

Estimated Annual Sales:

Describe your current and projected marketing methods. What marketing strategies do you plan to use to sell Qbased Healthcare products?
What other types of products and brands do you sell?

Direct Contact Person:
Email:
Phone:
Fax:
Additional Comments:

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Hours of Operation: Monday - Friday 8 am -7 pm CST

Q-Based Healthcare
110 East Edward Street
Erath, LA 70533
Telephone: 337-937-8800 or 1-800-609-9006

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